Friday, August 16, 2019

Random charts - Medicare & PBMs

"What GAO Found: Medicare Part D plan sponsors used pharmacy benefit managers (PBM) to provide 74 percent of drug benefit management services and performed the remaining 26 percent of services themselves in 2016—the most recent year of data at the time of our analysis. Plan sponsors are private entities that operate drug plans; PBMs are organizations that help manage drug benefits. Rebates and other price concessions—discounts generally paid by manufacturers to Part D plan sponsors and PBMs after the sale of a drug at the pharmacy—grew faster than Part D expenditures from 2014 through 2016. Specifically, gross expenditures (the amount paid to pharmacies by plan sponsors, or by the PBM on the sponsor’s behalf, and by the beneficiary) increased 20 percent, to $145.1 billion. During this period, rebates and other price concessions increased 66 percent, to $29 billion—20 percent of 2016 gross expenditures. Consequently, net expenditures (gross expenditures less rebates and other price concessions) increased only 13 percent, to $116.1 billion..."

Thursday, August 8, 2019

Turkmenistan's travails - redux

In September 2002 I penned an OPED bemoaning the unfortunate fact that the antics of 'Turkmenbashi' ("Head of all Turkmen," the then "Perpetual President of Turkmenistan," Sapamurat Niyazov) obscured the miserable lot of the ordinary folk of Turkmenistan...

I said: "... The total and utter ridiculousness of this situation makes an observer want to smile. But that is an unfortunate reaction. The buffoonery masks repression and misrule, under which the vast majority of Turkmenistan's citizens live a life of grinding poverty, while the country has vast reserves of natural gas and is the world's tenth largest producer of cotton. While the masses are hungry, Turkmenbashi spends money on grandiose projects (a 10 meter high gold-plated statue of Turkmenbashi atop a 72 meter tall tower surrounded by fountains, ornate palaces, Berzengi - a hotel and business center in the desert outside Ashkhabad that has 22 empty 5-star hotels built completely from imported materials), jails any opposition (some in psychiatric wards), has a tame and muzzled press, etc. As there are shortages of staples and hunger increases, Turkmenbashi has said, "Anyone who complains about going without sausage or bread for a day is not a Turkmen."

When he passed away in 2006 his Vice President, Gurbanguly Berdymukhammedov, took over in his stead, and a May 2008 blog entry noted that he had rolled back a couple of Turkmenbashi's actions. However, as time passed it became clear that not much was changed, as reflected in this November 2009 blog update entry.

We are now mid-way through 2019 and apparently not much has improved, see: Crazy-Ass President Of Turkmenistan Proves He's Not Dead By Doing Donuts Around 'Gateway To Hell.' 

Also view the video on YouTube: Watan Habarlary 04.08.2019

Tuesday, August 6, 2019

Random charts - healthcare

"Conditions aren’t uniform across the U.S., though. To determine where Americans receive the best and worst health care, WalletHub compared the 50 states and the District of Columbia across 43 measures of cost, accessibility and outcome. Read on for our findings, expert insight on the future of American health care and a full description of our methodology."

Monday, August 5, 2019

Kashmir... again

OK, so regarding Kashmir, the Indian parliament just  approved resolutions abrogating the special status of Jammu and Kashmir under Article 370 of the Indian constitution, and dividing the state of Jammu and Kashmir into two union territories. Prime Minister Narendra Modi tweeted out the following:
This was a mistake and is going to cause huge problems down the road... 
Back in 2002 India and Pakistan faced off across their border (the "Line of Control" that divides J&K), and at that time I wrote the following (see below), recommending that a solution (Kashmiri independence) be shoved down the throats of both India and Pakistan... Nothing was done...

01/14/2002 The conflict in Kashmir Brief History:

When the British were leaving the Indian subcontinent there were 570 'princely states' in the subcontinent ruled by hereditary rulers. The British gave the rulers of these states the option of acceding to India, to Pakistan, or of remaining independent. The majority of these states acceded to India, a few to Pakistan. Indian independence arrived August 15th, 1947. Problems arose in a few states that had princes who were of a different religion than the majority of their subjects:
  • The Nawab of Jugandah and the Nizam of Hyderabad were Muslim rulers of states that were predominantly Hindu. Hyderabad and Jugandah were also physically in proximity to territory that was becoming India. When the nawab attempted to accede to Pakistan India imposed an economic blockade and later armed a "liberation army" of Hindu emigrees to invade. The nizam did not decide immediately, but signed a one year "standstill agreement" with India to have extra time to decide. In September 1948 the Indian army invaded and took over Hyderabad. 
  • Unlike Hyderabad and Jugandah, Kashmir was ruled by Maharaja Hari Singh, a Hindu prince of a majority Muslim population. Kashmir also was located between India and Pakistan. The maharaja did not wish to make an immediate decision, perhaps hoping for independence. He signed a Standstill Agreement with India and Pakistan. There are two versions of what happened next

Pakistan's version of events:

The ruler of Kashmir, as a Muslim, wished to accede to Pakistan. He was placed under tremendous pressure by the Indian government to accede to India. The Muslim population, seeing this and the covert arrival of Indian troops, rose up and rebelled against Hari Singh. The government of India, alleging that the ruler had acceded to India on the basis of a fraudulent instrument of accession, invaded and occupied a large part of Kashmir, which is now divided into Azad (Liberated) Kashmir and 'Indian-held Kashmir'. India has reneged on its promise to hold a plebiscite to determine the wishes of the Kashmiris... India needs to implement UN resolutions calling for a referendum

India's version of events:

Pakistan implemented an economic blockade of Kashmir to force the maharaja to accede to Pakistan. When this failed Pakistan next sent armed Pathan tribesmen into Kashmir to forcibly annex it. Maharaja Hari Singh was thus obliged to seek India's assistance, and on October 26th 1947 Hari Singh signed the Instrument of Accession. Indian forces entered Kashmir and fighting continued until the battle stabilized. Eventually the United Nations arranged a cease-fire January 1st 1949 and the cease-fire line became known as the Line of Control. Approximately a quarter of the western portion of the state is occupied by Pakistan, with the remainder a part of India. A plebiscite has never been held as promised because Pakistan never fulfilled a prerequisite condition - the complete withdrawal of Pakistani troops from Kashmir. Subsequently, free and fair elections have been held in Kashmir. Lastly, the future of the disputed territory is to be worked out by bilateral negotiations between India and Pakistan as called for in the Simla agreement

The Future:

The ideal future would be an independent Kashmir. It is a beautiful region of snowcapped mountains and clear lakes, covering approximately 86,000 square miles. Once a tourist destination, it has been ravaged by years of fighting (Two faces of Kashmir - war and peace) and an estimated 60,000 people have died in the struggle between the two sides. The insurgents have carried out multiple acts of terror, while Indian troops have engaged in murder and torture, as documented by various human rights organizations e.g. Human Rights Watch.
Unfortunately independence is a highly unlikely scenario, as it would require both parties to show a level of flexibility far beyond what they have shown themselves capable of. The immediate prognosis is that Kashmir will remain a running sore between India and Pakistan for the foreseeable future. The interest shown by the US and the west in this latest flare-up is due to the fact that both countries are nuclear powers.
However, despite western concern, the likelihood of nuclear weapons being used even if the tensions between these two countries breaks out into a full-scale war is negligible. India has a declared "no first use" policy, possesses military superiority (both in terms of quantity and quality), and professional armed forces that are under civilian control. There are no scenarios in which tactical use of nuclear weapons would be militarily useful to Pakistan, and thus Pakistan would only use them as a weapon of last resort if the very existence of the country were in doubt. This is an unlikely scenario, since immense international pressure would be brought to bear on India before this point would be reached. Any armed conflict now would not involve nuclear weapons.
However, it is very likely that in five to ten years these countries will achieve advances in nuclear weapons, other weapons of mass destruction, and their delivery systems. This will significantly lower the nuclear threshold, and increase the risk of their use at a future point. Thus it is in everyone's interest that the question of Kashmir be resolved at this time when the risk of a nuclear exchange is low! The international community should push for a demilitarized and independent Kashmir as a solution to the problem

Sunday, August 4, 2019

Rinse and repeat - El Paso

April 2013's blog entry 'Anatomy of an Incident' listed the various stages that appear to routinely occur/play out after every mass shooting incident:

I. The Horror
II. The Coverage
III.  The Political Parade
IV. The Prohibition
V. The Search for a Hero
VI. The Search for a Reason
VII.  The Outpouring
VIII.  The Lionization
IX. The Debunking
X. Never Again!
XI. The Calls for Legislation
XII. Descent into Farce
XIII. The Fade-Out
XIV. The Next Horror

The recent outrages in El Paso and Dayton appear to be following the same well-worn 'script' although we have not yet reached the final stages (XII, XIII), as clearly demonstrated in the media and social media coverage:

Perhaps some day society will break out of this farcical cycle and things will actually change... This is devoutly to be hoped for!